Fillable Printable Sf2817
Fillable Printable Sf2817
Sf2817
Option B - Additional Option C - Family
Waiver of
all life
insurance
coverage
Option A - Standard
I followed the instructions on the back of Part 1.
See Privacy Act Statement on back of Part 3
Federal Employees' Group Life Insurance Program
I want Basic.
I authorize deductions to pay my share of the cost. (Basic may be provided without cost to Postal Service employees.)
Effective date of coverage
(mm/dd/yyyy)
Number of event
permitting change
I want no life insurance coverage. I understand that any life insurance I have will stop at the end of the last day of the pay period in which
my employing office receives this waiver. Further, I cannot get Basic life insurance unless (1) I wait at least 1 year after I sign this form
and
submit satisfactory results of a physical, or (2) I have a break in Federal service of at least 180 days, or (3) I participate in an open
enrollment period, which is held infrequently. I understand that I cannot get any optional insurance unless I first have Basic. I understand
that my decision to waive life insurance coverage now may affect my eligibility for coverage as a retiree.
This election supersedes all previous elections.
Fill in identifyin
g
information concernin
g
the employee.
If you signed for Basic in item 3 above, you may elect or retain any or all of the following options (UNLESS
you have previously
waived any or all of these options, in which case you may elect only those options which you are eligible to elect as outlined in the FEGLI
booklet.) Sign the box(es) below for any option(s) you are eligible for and wish to elect or retain. If you waive one or more o f the options,
your future opportunities to enroll in it are strictly limited.
You will not be covered for any option(s) for which you do not sign below,
regardless of whether you previously elected the option(s).
Form Approved:
OMB No. 3206-0230
Name
(Last) (First) (Middle)
Social Security NumberDate of birth
(mm/dd/yyyy)
To elect or retain Basic,
si
g
n and date below. If you do not si
g
n for Basic, you may not elect or retain any form of optional insurance. If
you do not want any insurance at all, skip to Section 5.
Employing department or agency
I want Option A.
I authorize deductions to pay the full cost.
I want Option B in the multiple of my annual basic
pay I indicate below. I authorize deductions to pay
the full cost.
I want Option C in the multiple I indicate below. I
understand that
each
multiple is worth $5,000 upon
the death of my spouse, and $2,500 upon the death
of an eligible child. I authorize deductions to pay the
full cost.
If you want NO life insurance coverage,
si
g
n and date below.
PART 1 - File in Official Personnel Folder
NSN 7540-01-231-4280
2817-104
Standard Form 2817
Rev. April 1999
Prior editions obsolete and unusable
The employee's copy of this form, when completed by the employing office, together with the FEGLI booklet ( RI 76-21 or RI 76-20 for Postal Service employees)
constitute the employee's Certificate of Insurance.
Signature of authorized agency official
To be completed
by agency
.
(See back of Part 2)
Name and address of employing office Date received in employing office
(mm/dd/yyyy)
Do not separate the parts. Give this form to your employin
g
office which will complete the form and return your copy to
you.
.
General Instructions
By law, unless you waive all covera
g
e or are ineli
g
ible, you are
automatically covered for Basic life insurance as an employee. When
you first become eli
g
ible for FEGLI, you may (1) elect Basic and any
or all of the options, (2) elect Basic but decline all of the options, or (3)
waive all life insurance covera
g
e. If you are chan
g
in
g
a previous
election, see the back of Part 3 - Employee Copy.
Signature
(Do not print. Only the Employee/Assi
g
nee may
si
g
n. Si
g
natures by
g
uardians, conservators or throu
g
h a
power of attorney are not acceptable.)
Signature
(Do not print. Only the Employee/Assi
g
nee may
si
g
n. Si
g
natures by
g
uardians, conservators or throu
g
h a
power of attorney are not acceptable.)
Signature
(Do not print. Only the Employee/Assi
g
nee may
si
g
n. Si
g
natures by
g
uardians, conservators or throu
g
h a
power of attorney are not acceptable.)
Signature
(Do not print. Only the Employee/Assignee may sign. Signatures by guardians, conservators or
through a power of attorney are not acceptable.)
Signature
(Do not print. Only the Employee/Assignee may sign. Signatures by guardians, conservators or
through a power of attorney are not acceptable.)
Date
(mm/dd/yyyy)
Date
(mm/dd/yyyy)
Date
(mm/dd/yyyy)
1 multiple
3 multiples
2 multiples
4 multiples
5 multiples
1 times my pay
3 times my pay
2 times my pay
4 times my pay
5 times my pay
.
Assi
g
nees completin
g
this form should read Items 5 and 6 on
the back of Part 3.
OWCP claim number,
if applicable
Date
(mm/dd/yyyy)
Date
(mm/dd/yyyy)
Remarks:
Department or agency location where employee works
(City, state,
ZIP Code)
Read the back of Part 3 - Employee Copy carefully.
.
Federal Employees
Group Life Insurance
Basic
Optional
2. Review of Completed Form
Agencies should review the original and both copies of SF 2817 to
see that they are legible and complete. If an employee signs the
box for Option A, Option B, or Option C, he o r she must also sign
item 3, Basic.
Only the employee may sign this form in items 3, 4, or 5, with one
exception (noted below). Signatures by guardians, conservators, or
through a power of attorney are not acceptable.
Exception: If the employee assigned his or her insurance, only the
assignee(s) may waive some or all of the employee's coverage. In
that case, the assignee(s) must sign the form (although the
information in Section 2 must refer to the employee). Please note
that assignees cannot increase the employee's coverage. Only the
employee can do that.
Instruct the employee that, while the agency will make sure that
the SF 2817 is complete, he or she is solely responsible for
ensuring that the SF 2817 accurately reflects his or her intentions.
3. Completion of Form
The Personnel Officer or his or her designated representative must
confirm that the employee is eligible for the coverage that he or
she has elected and sign the form in item 6.
4. Date Received
Enter the date the employing office received this form.
5. Number of Event Permitting Change
Enter the number of the event permitting a change, if applicable.
See the Table of Effective Dates on the back of Part 2 for event
numbers.
6. Effective Date of Coverage
Enter the effective date of coverage. For new and newly eligible
employees: Basic is effective on the first day the employee is at
work in a pay status; Optional coverage is effective on the first
day the employee is at work in a pay status on or after the day the
employing office receives the SF 2817. For changes in elections,
see the Table of Effective Dates on the back of Part 2. If the
employee elected more than one type of coverage and there is
more than one effective date, write in both dates and provide
details in the Remarks section.
7. Disposition of SF 2817
After completion, remove Part 3 and return it to the employee.
File Part 1 in the employee's personnel folder. Destroy Part 2 after
payroll office use.
8. Further Information
For further information, consult the FEGLI Handbook (RI 76-26)
or the FEGLI Booklet (RI 76-21 or RI 76-20 for Postal Service
employees), which are available on the FEGLI website at
www.opm.gov/insure/life.
Instructions for Agencies
1. Who Should File This Form
• New employees eligible for life insurance.
• Employees appointed to positions that allow life insurance
coverage following service in positions which did not allow
life insurance coverage.
• Employees who want to change their insurance.
• Reinstated employees who filed a previous waiver of life
insurance and who were separated from service for at least
180 days.
Give a new employee a copy of the FEGLI booklet (RI 76-21 or
RI 76-20 for Postal Service employees), when he or she reports
for duty and ask the employee to return the completed SF 2817 as
soon as possible (preferably before the end of the first pay period),
but no later than 31 days after his or her appointment.
Employees with prior service in nonexcluded positions who were
separated after March 31, 1981, will have an SF 2817 on file in
their personnel folders, and that election or waiver of coverage
may still be in effect. Do not accept a new SF 2817 unless the
employee has a break in Federal service of at least 180 days or is
eligible to cancel a previous waiver or declination that has been in
effect for at least one year.
Until an employee's SF 2817 on file is verified, make deductions
based on his or her statement about earlier insurance coverage in
the employee's Declaration for Federal Employment, OF 306, if
completed.
An employee may at any time file an SF 2817 to waive or reduce
coverage, unless the employee has assigned his/her insurance
coverage. If the employee has assigned the insurance, only the
assignee(s) may waive or reduce the coverage (except for Option
C which cannot be assigned).
An employee may elect or increase Basic, Option A, or Option B
insurance (but not Option C), if a signed waiver has been in effect
for more than one year, by submitting a Request for Insurance, SF
2822. If approved, ask the employee to submit an SF 2817
showing his or her election. More details are contained on the SF
2822.
An employee who is already enrolled in Basic may elect Option B
and/or Option C within 60 days following marriage, divorce,
spouse's death, or the acquisition of an eligible child. The number
of multiples he or she may elect (up to 5 total) is limited to the
following: (a) for marriage or acquisition of a child, the number of
additional family members; (b) for divorce or death of spouse, the
total number of the employee's dependent children.
An employee who is already enrolled in Option B and/or Option C
for at least one multiple may change to a higher multiple within 60
days following marriage, divorce, spouse's death, or the
acquisition of an eligible child. The number of multiples is limited
as listed in the previous paragraph.
Option B - Additional Option C - FamilyOption A - Standard
Waiver of
all life
insurance
coverage
Number of event
permitting change
(See back of Part 2)
Fill in identifying information concerning the employee.
Federal Employees' Group Life Insurance Program
Form Approved:
OMB No. 3206-0230
Name
(Last) (First) (Middle)
Social Security NumberDate of birth
(mm/dd/yyyy)
Employing department or agency
In item 7, box 2:
If this block is not signed, enter
0
If this block is signed, enter
1
In item 7, box 3:
If this block is not signed, enter
0
If this block is signed, enter the number
In item 7, box 4:
If this block is not signed, enter
0
If this block is signed, enter the number
marked "X" below
If you want NO life insurance coverage at all, sign and date below.
Effective date of coverage
(mm/dd/yyyy)
PART 2 - For Agency Use
NSN 7540-01-231-4280
2817-104
INSTRUCTIONS:
Enter codes in the boxes on the right as directed in items 4 and 5 above.
Standard Form 2817
Rev. April 1999
Prior editions obsolete and unusable
Signature of authorized agency official
To be completed
by agency.
Name and address of employing office Date received in employing office
(mm/dd/yyyy)
I followed the instructions on the back of Part 1.
SF 50
Equivalent
Signature
(Do not print. Only the Employee/Assignee may
sign. Signatures by guardians, conservators or through a
power of attorney are not acceptable.)
Signature
(Do not print. Only the Employee/Assignee may
sign. Signatures by guardians, conservators or through a
power of attorney are not acceptable.)
Signature
(Do not print. Only the Employee/Assignee may
sign. Signatures by guardians, conservators or through a
power of attorney are not acceptable.)
Signature
(Do not print. Only the Employee/Assignee may sign. Signatures by guardians, conservators or
through a power of attorney are not acceptable.)
Date
(mm/dd/yyyy)
Date
(mm/dd/yyyy)
Date
(mm/dd/yyyy)
Signature
(Do not print. Only the Employee/Assignee may sign. Signatures by guardians, conservators or
through a power of attorney are not acceptable.)
1 multiple
3 multiples
2 multiples
4 multiples
5 multiples
1 times my pay
3 times my pay
2 times my pay
4 times my pay
5 times my pay
In item 7: If this block is signed, enter 998
OWCP claim number,
if applicable
Date
(mm/dd/yyyy)
Date
(mm/dd/yyyy)
Department or agency location where employee works
(City, state,
ZIP Code)
INSURANCE SF 50
INELIGIBLE A0
0000 B0
1000 C0
1100 D0
1001 E1
1002 E2
1003 E3
SF 50 Equivalents of Insurance Codes
1004 E4
1005 E5
1101 F1
1102 F2
1103 F3
1104 F4
1105 F5
1010 G0
1110 H0
1011 I1
1012 I2
1013 I3
1014 I4
1015 I5
1111 J1
1112 J2
1113 J3
1114 J4
1115 J5
1020 K0
1120 L0
1021 M1
1022 M2
1023 M3
1024 M4
1025 M5
1121 N1
1122 N2
1123 N3
1124 N4
1125 N5
1030 90
1130 P0
1031 Q1
1032 Q2
1033 Q3
1034 Q4
1035 Q5
1131 R1
1132 R2
1133 R3
1134 R4
1135 R5
1040 S0
1140 T0
1041 U1
1042 U2
1043 U3
1044 U4
1045 U5
1141 V1
1142 V2
1143 V3
1144 V4
1145 V5
1050 W0
1150 X0
1051 Y1
1052 Y2
1053 Y3
1054 Y4
1055 Y5
1151 Z1
1152 Z2
1153 Z3
1154 Z4
1155 Z5
In Item 7: If this block is not signed, enter
0
in
ALL FOUR
boxes.
If this block is signed, enter
1
in box
1
.
134
Insurance Code
2
Federal Employees
Group Life Insurance
Basic
B.Not applicable.
Table of Effective Dates: Changes in Life Insurance Election
Deductions:
Begin, increase, stop or decrease with the pay period in which coverage begins, increases, stops or decreases.
Event Allowing Change
Change Permitted?
(To enroll in any option, employee must enroll or be enrolled in Basic)
Basic Option A - Standard Option B - Additional Option C - Family
1.Approval of Request for
Insurance (SF 2822)
by the Office of Federal
Employees' Group Life
Insurance (OFEGLI).
Yes.
Coverage
is effective on the first day the employee
is at work in a pay status after date of OFEGLI's
approval.
Time Limit
- OFEGLI's approval expires after
31 days. If employee is not at work in a pay status within
those 31 days, Basic does
not
become effective.
Employee must obtain a new physical.
Yes. Coverage
is effective on the first day the employee
is at work in a pay status on or after date of OFEGLI's
approval
and
agency receives the SF 2817.
Time Limit
-
Employee must submit SF 2817 and be at work in a
pay status within 31 days after date of OFEGLI's
approval. If employee is not at work in a pay status or
doesn't submit the SF 2817 within those 31 days, Option
A does
not
become effective. Employee must obtain a
new physical.
Same as Option A. No change permitted for this event.
2.Marriage, divorce, death
of spouse or acquisition of
an eligible child.
No change permitted for this event. No change permitted for this event.
Yes
.
Employee may elect or increase multiples (limited
to 5 total) up to (a) for marriage or children, the number
of additional family members; (b) for divorce or death of
spouse, the total number of dependent children. Foster
children are not considered family members or
dependent children for Option B purposes.
Coverage
is
effective on the first day the employee is at work in a pay
status on or after the agency receives the SF 2817.
Time
Limit
- Agency must receive SF 2817 and proof of the
event within 60 days after date of event. (Time limit may
be extended if event occurs when employee was
separated from Federal service or 6 0 days or less before
separation.
)
Yes. Employee may elect or increase multiples (limited
to 5 total) up to (a) for marriage or children, the number
of additional family members; (b) for divorce or death of
spouse, the total number of dependent children.
Coverage
is effective the day the agency receives the SF
2817, if employee submits the election within 60 days
after the event.
Coverage
is effective the day of the
event, if employee submits the election prior to the event.
Time Limit
-
Agency must receive SF 2817 and proof
of the event within 60 days after date of event. (Time
limit may be extended if event occurs when employee
was separated from Federal service, 60 days or less
before separation, or during the year following waiver of
Basic.)
3.Employee is reinstated
after a break in service of
at least 180 days in a posi-
tion that is not excluded
from life insurance by law
or regulation.
Yes. Coverage
is effective on the first day the employee
is at work in a pay status, if no new waiver is filed.
Yes.
Employee may elect any or all optional insurance
within 31 days after reinstatement.
Coverage
is the same
as with new employees. However, if employee does not
submit SF 2817 electing such coverage to his/her agency
within 31 days after reinstatement, he/she has the same
Optional insurance carried immediately before his/her
break in service.
Same as Option A.
Same as Option A.
4.Employee returns to
Federal Service after a
break in service of at least
180 days in a position
that is excluded from life
insurance by law or
regulation.
No.
However, if employee is later converted to a
non-excluded position, the coverage is effective on the
first day the employee is at work in a pay status on or
after being converted to such a position.
No.
However, if employee is later converted to a
non-excluded position, the coverage is effective on the
first day the employee is converted to such a position
wherein he or she is at work in a pay status on or after
the date the agency receives the SF 2817 electing such
coverage.
Time Limit
-
Employee must submit SF 2817
electing such coverage to his or her agency within 31
days after conversion.
Same as Option A. Same as Option A.
5A.Employee initially
waives or subsequently
cancels life insurance
coverage.
A.
Yes. Coverage
stops at the end of the last day of the
pay period in which the agency receives the SF 2817,
with
no
31-day extension of coverage.
Time Limit
-
None. Employee may cancel coverage at any time.
However, if the insurance is assigned, only the
assignee(s) may cancel coverage – the employee
may not.
A. Same as Basic. A. Same as Basic. A. Same as Basic, except information on assignment is
not applicable.
5B.Employee (or if applica-
ble, assignee(s)) elects
to decrease optional
coverage.
B. Not applicable. B.
Yes
. Employee may at any time reduce the number of
multiples, unless the insurance has been assigned. In
that case, only the assignee(s) may reduce coverage –
the employee may not.
Coverage
reduces effective on
the last day of the pay period in which the agency
receives the SF 2817.
B.
Yes
. Employee may at any time reduce the number of
multiples.
6.Open Enrollment Period. If permitted under conditions specified by OPM. Same as Basic. Same as Basic. Same as Basic.
or
I want Option C in the multiple I indicate below. I
understand that each multiple i s worth $5,000 upon
the death of my spouse, and $2,500 upon the death
of an eligible child. I authorize deductions to pay the
full cost
I want Option A.
I authorize deductions to pay the full cost.
Fill in identifyin
g
information concernin
g
the employee.
Federal Employees' Group Life Insurance Program
Form Approved:
OMB No. 3206-0230
Name
(Last) (First) (Middle)
Social Security NumberDate of birth
(mm/dd/yyyy)
To elect or retain Basic,
si
g
n and date below. If you do not si
g
n for Basic, you may not elect or retain any form of optional insurance. If
you do not want any insurance at all, skip to Section 5.
Employing department or agency
I want Option B in the multiple of my annual basic
pay I indicate below. I authorize deductions to pay
the full cost.
If you want NO life insurance coverage,
si
g
n and date below.
PART 3 - Employee Copy
NSN 7540-01-231-4280
2817-104
Standard Form 2817
Rev. April 1999
Prior editions obsolete and unusable
See Privacy Act Statement on back of Part 3
The employee's copy of this form, when completed by the employing office, together with the FEGLI booklet
(RI 76-21 or RI 76-20 for Postal Service employees)
constitute the employee's Certificate of Insurance.
Signature of authorized agency official
To be completed
by agency
.
Number of event
permitting change
(See back of Part 2)
Name and address of employing office Date received in employing office
(mm/dd/yyyy)
Effective date of coverage
(mm/dd/yyyy)
I followed the instructions on the back of Part 1.
General Instructions
By law, unless you waive all covera
g
e or are ineli
g
ible, you are
automatically covered for Basic life insurance as an employee. When
you first become eli
g
ible for FEGLI, you may (1) elect Basic and any
or all of the options, (2) elect Basic but decline all of the options, or (3)
waive all life insurance covera
g
e. If you are chan
g
in
g
a previous
election, see the back of Part 3 - Employee Copy.
Signature
(Do not print. Only the Employee/Assi
g
nee may
si
g
n. Si
g
natures by
g
uardians, conservators or
throu
g
h a
power of attorney are not acceptable.)
I want no life insurance coverage. I understand that any life insurance I have will stop at the end of the last day of the pay period in which
my employing office receives this waiver. Further, I cannot get Basic life insurance unless (1) I wait at least 1 year after I sign this form
and submit satisfactory results of a physical, or (2) I have a break in Federal service of at least 180 days, or (3) I participate in an open
enrollment period, which is held infrequently. I understand that I cannot get any optional insurance unless I first have Basic. I understand
that my decision to waive life insurance coverage now may affect my eligibility for coverage as a retiree.
Signature
(Do not print. Only the Employee/Assignee may sign. Signatures by guardians, conservators or
through a power of attorney are not acceptable.)
I want Basic. I authorize deductions to pay my share of the cost. (Basic may be provided without cost to Postal Service employees.)
Signature
(Do not print. Only the Employee/Assignee may sign. Signatures by guardians, conservators or
through a power of attorney are not acceptable.)
Date
(mm/dd/yyyy)
Date
(mm/dd/yyyy)
Date
(mm/dd/yyyy)
1 multiple
3 multiples
2 multiples
4 multiples
5 multiples
1 times my pay
3 times my pay
2 times my pay
4 times my pay
5 times my pay
OWCP claim number,
if applicable
If you signed for Basic in item 3 above, you may elect or retain any or all of the following options (UNLESS you have previously
waived any or all of these options, in which case you may elect only those options which you are eligible to elect as outlined in the FEGLI
booklet.) Sign the box(es) below for any option(s) you are eligible for and wish to elect or retain. If you waive one or more o f the options,
your future opportunities to enroll in it are strictly limited. You will not be covered for any option(s) for which you d o not sign below,
regardless of whether you previously elected the option(s).
Date
(mm/dd/yyyy)
Date
(mm/dd/yyyy)
Remarks:
Department or agency location where employee works
(City, state,
ZIP Code)
Signature
(Do not print. Only the Employee/Assi
g
nee may
si
g
n. Si
g
natures by
g
uardians, conservators or
throu
g
h a
power of attorney are not acceptable.)
Signature
(Do not print. Only the Employee/Assi
g
nee may
si
g
n. Si
g
natures by
g
uardians, conservators or
throu
g
h a
power of attorney are not acceptable.)
.
Read the back of Part 3 - Employee Copy carefully.
Assi
g
nees completin
g
this form should read Items 5 and 6 on
the back of Part 3.
.
.
Do not separate the parts. Give this form to your employin
g
office which will complete the form and return your copy to
you.
This election supersedes all previous elections.
Federal Employees
Group Life Insurance
Waiver of
all life
insurance
coverage
Option A - Standard
Basic
Optional
Option B - Additional Option C - Family
1. General Information
The major provisions of this program are described in the Federal Employees' Group
Life Insurance (FEGLI) booklet (RI 76-21 or RI 76-20 for Postal Service employees,
available from your employing office). Please read the entire booklet carefully. Your
completed copy of this election form and the FEGLI booklet constitute your
certification of coverage.
2. New Employees and Employees Newly Eligible for Life Insurance
You are automatically enrolled in Basic unless you waive it. If you waive Basic, you
automatically waive all forms of Optional insurance. You will not have any Optional
insurance unless you elect it.
To elect Basic: You do not need to submit this form unless you also wish to elect
Optional insurance. If you do not submit this form, you will have Basic, but no
Optional coverage.
To waive Basic: Sign Section 5 of the form and give it to your employing office.
Your agency will withhold Basic premiums from your salary from your first day at
work in a pay status UNLESS you submit your waiver before the end of your first pay
period.
To elect Optional: Sign Section 3 and one or more of the blocks in Section 4 of the
form and give it to your employing office within 31 days after the date you are
appointed or first become eligible for life insurance.
To waive Optional: If you do not sign for a particular type of Optional coverage in
Section 4, you automatically waive that coverage. If you do not submit the form at all,
you will have Basic, but no Optional coverage.
3. Employees With Prior Government Service
A life insurance election or waiver on SF 2817 filed during a prior period of Federal
employment stays in effect unless you change coverage or have a break in service of at
least 180 days.
A break in service of at least 180 days cancels any previous waiver of insurance.
Unless you file a new waiver, Basic becomes effective on the first day you actually
enter on duty in a pay status in a position in which you are eligible for coverage. You
can elect any amount of Optional insurance within 31 days of returning to service,
regardless of the coverage you had during previous employment. If you fail to elect
any Optional insurance, you will automatically get the Optional insurance you carried
immediately before your break in service.
If you had a break in service of less than 180 days and were eligible in your last period
of Federal employment, your life insurance in your new employment will be the same
as you had then and if you waived coverage then, the waiver is still in effect. Your
opportunities to cancel your waiver or to enroll in an option you previously declined
are strictly limited. See the FEGLI booklet.
4. Reemployed Annuitants
If you waive your insurance as a reemployed annuitant, you also waive your insurance
as an annuitant, and you will have no Federal life insurance.
5. Assignment
If you have assigned your insurance by filing an RI 76-10, Assignment of Federal
Employees' Group Life Insurance, you may not cancel any of your current insurance
coverage. Only the assignee(s) may cancel your coverage. However, you may elect
new coverage if you otherwise meet the requirements for electing such coverage. Any
new coverage you elect will automatically be subject to your existing assignment,
except for Option C, which you cannot assign. All assignments are automatically
canceled after a break in service of at least 31 days, or upon cancellation of all life
insurance coverage by the assignee(s).
6. Attention Assignees
If you are completing this form in order to cancel some or all of the employee's life
insurance coverage, you must sign the form. The information in Section 2 of the form
refers to the employee, but you must sign in Section 3, 4 or 5, as applicable. Indicate
"assignee" after your signature. Return the completed form to the employee's
employing office.
7. How to Complete and Review Your Election Form
Follow the instructions for each item carefully. After you fill out the form, review it to
be sure it is complete and correct. The following checklist should help.
If you sign item 3, you elect (or retain) Basic. Do not also sign item 5. (You cannot
elect (or retain) and waive coverage.)
If you sign any block in item 4, you must also sign item 3. (To elect (or retain) an
option, you must also elect (or retain) Basic.)
If you sign item 4 for Option B and/or Option C, you must also mark one of the
five boxes to show how many multiples you wish to elect (or retain). Do not mark
more than one.
Be sure you sign for all options you want. This election supersedes all previous
ones. If you have optional coverage and wish to keep it, you must sign the appropriate
box(es). If you do not sign for it, you have waived it.
If you sign item 5, you waive Basic. Do not sign item 3 or any block in item 4. (You
cannot waive and elect coverage.)
Only you, the employee, may sign this form. Signatures by guardians, conservators,
or through a power of attorney are not acceptable. Exception: If you have assigned
your insurance, only the assignee(s) may cancel some or all of your coverage. In that
case, the assignee(s) must sign the form (although the information in Section 2 must
refer to you).
REMEMBER THAT YOU, NOT YOUR AGENCY, ARE RESPONSIBLE FOR
ENSURING THAT YOUR SF 2817 IS CORRECT AND ACCURATELY
REFLECTS YOUR INTENTIONS.
8. 1999 Open Enrollment Period
If you elected coverage during the 1999 Open Enrollment Period, and that coverage
has not yet become effective, and you want to make a further change to your FEGLI
coverage on this SF 2817, you should check with your employing office. That office
can tell you about any special election procedures that may apply.
9. Waiving or Changing Your Insurance Coverage
If you do not sign for a particular type of coverage, you have waived that coverage. If
you waive Basic or one or more of the options, your opportunities to enroll in the
coverage you waived are strictly limited. A waiver may also affect your eligibility to
continue coverage into retirement. See the FEGLI booklet.
10. Compensationers
If you are receiving compensation payments from the Office of Worker's
Compensation Programs (OWCP), provide your OWCP number in Section 2 of the
form. If you are still employed, return the completed form to your employing office. If
you are not still employed, return the completed form to OPM, Retirement Operations
Center, Boyers, PA 16017-0001.
11. Where to Send Completed Form
After you have completed this form and verified that it accurately reflects your
intentions, send the entire form (without separating the parts) to your employing
office.
12. How to Verify that Your Agency Processed Your Election
After your employing office processes your election form, you will receive an SF 50,
Notice of Personnel Action. A two digit code appearing on the SF 50 will explain your
insurance coverage. These codes are explained on Part 2 of the SF 2817. Also check
your pay statement for the correct withholdings. Compensationers no longer employed
will receive a notice from OPM which will explain their insurance coverage.
13. Further Information
For further information, consult the FEGLI Handbook (RI 76-26) or the FEGLI
Booklet (RI 76-21 or RI 76-20 for Postal Service employees), which are available on
the FEGLI website at www.opm.gov/insure/life.
Instructions for Employees
Chapter 87, title 5, U.S. Code, Federal Employees' Group Life Insurance, authorizes solicitation of this information. The data you furnish will be used to determine your life insurance coverage. This
information may be shared and is subject to verification, via paper, electronic media, or through the use of the computer matching programs, with national, state, local or other charitable or social security
administrative agencies to determine and issue benefits under their programs or law enforcement agencies, when they are investigating a violation or potential violation of the civil o r criminal law. Public
Law 104-134 (April 26, 1996) requires that any person doing business with the Federal government furnish a Social Security Number or tax identification number. This is an amendment to title 31, Section
7701. Failure to furnish the requested information may result in OPM's inability to determine your life insurance coverage.
We think this form takes an average of 15 minutes to complete including the time for getting the needed data and reviewing both the instructions and completed form. Send comments regarding our estimate
or any other aspect of this form, including suggestions for reducing completion time, to the Office of Personnel Management (OPM), Reports and Forms Manager, Paperwork Reduction Project
(3206-0230), Washington, DC 20415. The OMB Number, 3206-0230 is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.
Privacy Act and Public Burden Statements
